and Answers 100% Pass Guaranteed
When do *advanced directives* go into effect? - Correct answer-when person is
*unable to speak for him/herself* due to either:
1. *Mental Incapacity* - *coma *(GCS score ≤ 7)
2. *Aphasia*
(≠as soon as signed; directives can always be changed later by person)
SBAR Communication Framekwork Components - Correct answer-1. *S* =
Situation - what *prompted* the communication (eg *what* changes occurred)
2. *B* = Background - *pertinent information, relevant history, vital signs*
3. *A* = Assessment - nurse's assessment of the situation (*when* & *what
changes* occurred)
4. *R* = Recommendation - *request* for *prescription* or *action* from HCP
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,Appropriate order of actions when client found on floor - Correct answer-1.
*Assessment* of *physiological stability* (ABCs)
2. *Assessment* of *injuries*
3. *Moving client*
4. *Notifications*
5. *Documentation*
Conditions of being *ineligible to leave AMA* - Correct answer-1 *danger to self
or others*
2. *lack of consciousness*
3. *Altered consciousness*
4. *Mental illness*
5. Being under *chemical influence*
6. *Court decision*
Effective handoff communication components - Correct answer-Nurse should:
1. Provide *identifying information* (eg client's name and room number)
2. Note *care priorities* and upcoming or outstanding tasks (eg time to replace
medication infusion bag, need to perform delayed wound care and cause of delay)
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,3. Provide *exact, pertinent information* (eg medication dose, time, measurable
outcomes)
4. Include *multidisciplinary plans* (eg radiology examinations, family meetings,
physical therapy)
5. Relay significant client changes in a clear manner
*Risk factors* for *cervical cancer* - Correct answer-1. Infection with high-risk
HPV strains
2. History of sexually transmitted diseases
3. Early onset of sexual activity
4. Multiple or high-risk sexual partners
5. Immunosuppression
6. Oral contraceptive use
7. Low SES
8. Tobacco use
what medications interact with grapefruit? - Correct answer-1. *calcium channel
blockers* (diltiazem, nifedipine, verapamil, etc)
2. *statins*
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, 3. *SSRIs*
Risk associated with *stent placement* using the *femoral approach* - Correct
answer-*retroperitoneal hemorrhage*
what are early signs of bleeding into the retroperitoneal space? - Correct answer-
hypotension, back pain, flank ecchymosis (grey turner sign), hematoma formation,
diminshed distal pulses
what is the grey-turner sign and what is it a sign of? - Correct answer-bruising of
the flanks and retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? - Correct answer-
intermittent calf muscle pain?, rest pain, hair loss, decreased peripheral pulses,
cool, dry, shiny skin, thick brittle nails, gangrene, ulcers (all of these are in the
extremities)
transplanted hearts are expected to be - Correct answer-tachycardic like 90-110
what is the priority intervention for pain with sickle cell crisis and why? - Correct
answer-administer IV fluids to reduce blood viscosity and restore perfusion to
areas affected by vasoocclusion
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